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Patient Name
Date of Birth
Primary Care Physician
Endoscopist
Procedure
Reason for Procedure
May we leave medical information on an answering machine or voicemail? Yes No
May we discuss procedure results with anyone other than you? Yes No If yes, who?
Do you have an advance directive (Health Care Proxy)? Yes No If yes, who?
If No, would you like any additional information? Yes No
Name
Telephone Number
Heart disease/Murmur/Valve disease Yes No
Explanation if yes
High Blood Preassure Yes No
Breathing/Lung problems Yes No
Seizures/Stroke/Epilepsy Yes No
Liver or Kidney Disease Yes No
Diabetes Yes No
Arthritis/Limitations of movement Yes No
Bleeding problems/Blood thinners Yes No
Problems with anesthesia or sedation Yes No
Recreational drug use? Yes No
Are you pregnant or nursing? Yes No
Pregnancy test taken? Yes No
Pregnancy test waiver signed (if applicable)? Yes No
Do you drink alcohol? How much?
Do you smoke? How much? How long?
Any other medical problems not listed above? List surgical operations
Are you allergic or sensitive to medications? Yes No
If yes, list medication(s) and type of reaction
Are you allergic or sensitive to other materials? Yes No
If yes, list material(s) (latex, iodine, etc) and type of reaction
Do you wear dentures or have a removable bridge? Yes No
When did you last eat?
When did you last drink?
Additional information you would like to give to your doctor about this procedure:
If you recieve sedation, you may not operate a motor vehicle, mechanical/electrical equipment, or make any critical decisions until the next day after your procedure. Doing any such activities could lead to injury to yourself and/or others.
Patient/Authorized representative signature (full name)